1例精氨酸输液不当导致皮肤坏死的治疗实践

A case study:the therapeutic experience for skin necrosis caused by improper arginine infusion

目的探讨防范高渗性药物输液不当造成不良事件的措施。方法临床药师参与救治1例精氨酸输液不当导致皮肤坏死的患者,分析该不良事件发生的原因,并提出解决办法及预防措施。结果经硫酸镁外敷、清创减压、防感染等处理后,患处淤紫全部吸收,创面恢复佳。结论应加强审核医嘱的环节,临床药师辅助医生用药,保障患者用药安全。

Objective To discuss the measures to prevent adverse events caused by misused hyperosmolar drugs.Methods Clinical pharmacists were involved in the treatment of one case of skin necrosis caused by hyperosmolar arginine infusion,analyzing the cause of the adverse events and proposing solutions and preventative measures.Results Treatment includs external application of Epson salt,debridements,infection prevention and so on were implemented.All bruises were absorbed with good wound healing.Conclusion Clinical pharmacist should play a role in examining prescriptions and ensuring drug safety for patients.